Utilization of care at the end of life in Medicare decedents with advanced cancer.

Abstract

22 Background: Despite increasing evidence supporting minimization of aggressive care at the end of life, little literature exists reporting timing of chemotherapy and radiation in relation to hospice referral. Methods: Deceased Medicare beneficiaries age ≥65 years with stage IV cancer at 12 sites in 5 southeast US states were identified from 2012-2015. All utilization of radiation, chemotherapy, hospice, hospitalizations, and emergency department [ED] visits were abstracted and tabulated from Medicare claims during the last 6 months of life. Results: Among 3516 deceased patients, median age at time of metastatic disease was 73 years (IQR 68-79). Most patients were white (81%), male (55%), with two or more comorbidities (54%). The most common primary cancer sites were lung (38%), gastrointestinal (27%), and genitourinary (10%). In the last 6 months of life, 65% and 66% of patients visited the ED or were hospitalized; 11% received radiation and 28% received chemotherapy. Median days from last course of treatment to death for patients with chemotherapy (n = 978) was 45 days (IQR 23-83) and with radiation (n = 380) was 52 days (IQR 19-100). After completion of radiation, 54% of patients continued to receive systemic therapy. In subset analysis of patients with a hospice referral after final delivery of radiation and/or chemotherapy (n = 768), there was persistent late referral to hospice. Patients referred to hospice within 0-7 days of completing radiation or chemotherapy had similar median length of time on hospice when compared to those referred to hospice between 91-180 days after treatment (median 14 [IQR 4-35] vs. median 18 [IQR 8-43] days). Conclusions: In decedents with poor performing cancer histologies, low utilization of hospice and high rates of ED visits and hospitalization remain. Late referral to hospice persisted irrespective of last course of radiation or chemotherapy timing. High utilization of hospitalization and emergency visits at EOL may be ameliorated by earlier hospice referral.